Leslie Cloud, MD Department of Neurology Division of Movement Disorders Emory University School of Medicine.

Leslie Cloud, MDDepartment of Neurology

Division of Movement DisordersEmory University School of Medicine

The videos shown in this lecture were filmed in the Movement Disorders Clinic at Emory University.

All patients provided written consent for the filming of their examination to be used for educational purposes.

All videos have been edited to protect patient privacy.

Rest tremor: occurs in a body part that is not voluntarily activated and is completely supported against gravity ↑ with activation↓ with voluntary action

Action tremors: any tremor occurring on voluntary contraction of muscle postural kinetic –simple vs. intentiontask-specificisometric

Topography Head Chin JawUpper/lower extremityTrunk

Activation conditionRestPostureSpecific tasks

Frequency low <4 HZmedium 4-7 Hz high >7 Hz

Amplitude

Medical history should include details of tremor onset, family history, alcohol sensitivity, associated diseases, medications, and drug use/abuse.

The general neurological exam is very important and has a great impact on the differential diagnosis.

Clinical situation should guide additional workup (labs, imaging, etc…)

Physiological tremor is present in every normal subject with posture and action.

Enhanced physiological tremor is a visible, predominantly postural, and high frequency tremor of short duration (<2 years). Evidence for neurological disease related to the tremor must be excluded.HyperthyroidismDrugs (TCAs, Lithium, bronchodilators,

cocaine, alcohol,...)

Predominantly posture and action tremor that is usually slowly progressive over time. Rarely, resting tremors can also occur.

Mean onset between 35-45 years of age.

Prevalence rates vary from 0.4-5.6%. AD in 60% 50-90% improve with alcohol ingestion. Topography:

hand>head>voice>leg>jaw>trunk/face

First choice:Propranolol LA (60-240 mg daily)Primidone (150 mg qhs)

Second line ClonazepamGabapentinTopiramate

Medically-Refractory cases:DBSThalamotomy

http://www.mdvu.org/library/ratingscales/et/

Classic Parkinsonian tremor:Rest tremorAsymmetricTemporarily suppressed with voluntary

movement Increased amplitude with mental stress,

contralateral movements, and during gait Treat with anti-Parkinsonian agents and

DBS in medically-refractory cases of tremor-predominant PD

AKA intention tremors Pure intention tremor Often unilateral Slow (<5 Hz) Postural tremor may be present but no

rest tremor Medical treatments typically ineffective

Neuroleptics Reglan Antiepileptics (especially VPA) Antidepressants Steroids Antiarrhythmics (especially amiodarone) Cyclosporine Cytostatics (e.g. vincristine)

Postural and kinetic tremor not usually seen during complete rest that occurs in a body part affected by dystonia.

They are focal tremors with irregular amplitudes and variable frequencies.

Geste antagoniste Botulinum toxin treatment of first choice DBS for medically-refractory cases

Most common PMD Tend to be equal at rest, with posture holding

and with action Highly variable within the same individual Fingers rarely involved Co-activation sign (tremor amplitude ↑ when

weight applied to the involved limb) Entrainment Distractible May emerge during a period of emotional

stress May have other psychogenic features on

exam

25 year old woman with tremor for two years.

Bilateral hands and head affected. Alcohol helps the tremor. Anxiety makes it worse. Father has hand tremor. Told by 2 other neurologists that she

has ET. Propranolol not tolerated. On primidone now without much

benefit.